ICES | Emergency Department Services in Ontario 1993 - 2000 - page 9

time off from work. An incentive structure may need to be established to
encourage individuals to work during these time periods.
Regional Variations
There was marked variation in ED use across the province. The higher rate of
utilization in Northern Ontario deserves further research. Possible explanations
for this occurrence may be that small, remote communities do not have the
population size to sustain the creation of walk-in clinics, or that access to
primary care in these communities may be limited.
The high net inflows into selected regions of Southern Ontario also deserves
further research. One possibility is that these areas are prime cottage country
and receive large numbers of urban residents during summer and holiday
periods. Policy makers and hospital management need to take these patient
flows into consideration when planning ED infrastructure and staffing levels.
ED Physician Workforce
Supply and Training
The number of physicians practicing in EDs has declined substantially over
the past decade. Those who do work in EDs tend to have more emergency
training than in the past and have heavier clinical workloads. There are
several potential benefits and drawbacks of such a development. Having
physicians with extra qualifications who devote more of their time to emergency
medicine may improve quality of care. These physicians may also act as a
resource to those GP/FPs who do continue to practice in EDs. On the other
hand, the decline in the number of ED physicians raises questions about
whether there will be sufficient supply in the future. Fewer physicians may
also reduce the degree of flexibility available when designing call schedules.
Furthermore, as GP/FPs reduce their work in EDs, they will have limited
contact with an environment that may provide enhanced peer interactions
and varied clinical exposure. Such exposure may help GP/FPs to maintain
their clinical skills in the management of complex patients.
Policy makers need to examine these trends to determine whether or not they
best reflect community needs. At present, there is no formal process for
planners to determine what is the optimal mix of physicians of different types
for individual communities in the province.
15
There is also no mechanism to
feed this information to medical schools and residency programs, so that the
output from these programs will match community needs. This problem
affects physician human resource planning for all specialties, not just those
related to emergency medicine.
Planners should also recognize that different regions have different needs.
Small rural communities in particular may prefer having GP/FPs staff their EDs
because they may not have the critical mass to sustain a group of physicians
dedicated to working primarily in EDs. Alternatively, EDs in larger cities, such
as those in teaching hospitals, may insist on a higher level of training among
their physician staff.
Demographics of the Workforce
Emergency medicine has traditionally been the domain of younger physicians,
but, in recent years, the average age of physicians working in EDs has
increased. This trend is consistent with past ICES research showing that,
over the past decade, the number of newly trained physicians starting
practice in Ontario has decreased and the average age of physicians has
increased.
16
During the 1990’s, policies were enacted to limit growth in the
supply of physicians, but most of these policies were aimed at young
physicians, such as the restriction of new billing numbers for out-of-province
graduates
17
and penalties for physicians starting practice in urban areas.
18
These policies may have discouraged some young physicians from working in
Ontario and may have had a disproportionate impact on the ED workforce.
Recommendations for Improving Data and Standards
This study is limited by the absence of fee-for-service data for all EDs.
Furthermore, fee-for-service data, while useful for examining utilization trends,
are limited in the amount of clinical information available to determine the
appropriateness of the visit or the quality of care. The new National Ambulatory
Care Reporting System (NACRS) will address some of these limitations. It is
strongly recommend that all EDs submit data to NACRS and shadow billings
to OHIP so that all EDs can be compared on an equal footing.
Another difficulty in conducting this study is the lack of a standard definition
for an ED. In some instances, hospitals reported that they did not believe they
had an ED, yet emergency department fee codes were being billed from their
ambulatory care departments. It is recommended that the Ministry develop a
standard classification system for facilities that primarily accept unscheduled
patients for episodic care. Some of the characteristics which might be
considered in defining an ED include the following:
Emergency Department Services in Ontario
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Institute for Clinical Evaluative Sciences
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